Читать книгу Commentaries on the Surgery of the Npoleonic War in Portugal, Spain, France, - G. J. Guthrie - Страница 15

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SECONDARY AMPUTATIONS, ETC.

130. Secondary amputations, or those performed after the lapse of six or more weeks from the receipt of an injury, when suppuration has been fully established, are not as successful in military as in civil hospitals, in which these operations are more commonly performed for incurable diseases than for injuries. When, however, they are done in them for injuries, they are not equally successful.

131. In military warfare these amputations are frequently done from necessity, not choice, after the first forty-eight hours; and especially after four or five days to the end of six weeks, in parts which have been lately, or are still affected by some of the accompaniments of inflammation, or are in a state of irritation. In these cases the cellular or areolar tissue has become firmer and more compact than usual; the muscles are not perfectly healthy; the blood-vessels are larger and more numerous, and ready to assume actions unusual to them in a state of health. Where the bones have been diseased, much bony matter may be deposited between the muscles, and in some cases the vessels even are surrounded by it. After a few hours’ remission, the constitutional symptoms often return, the wound sloughs, and secondary hemorrhage is not an infrequent consequence. The ligatures are a source of irritation, and prevent union, which, in fact, should not in such cases be attempted, and, if attempted, will as rarely succeed.

132. In these states of constitutional derangement, inflammation of the veins and sloughing of the stump are not uncommon, augmented by, if not dependent in some degree on, the state of the atmosphere, which in autumn, the season for many military movements, gives rise to endemic fevers, and even to dysenteries and cholera, which the soldier is often so unfortunate as to acquire in crowded hospitals. If the man should escape with life, a joint will frequently be lost which might have been saved, if the operation had been performed in the first instance below it. When the injury is in the thigh, this is a most important point for consideration.

133. If the sufferer should escape these dangers, there remain the sudden and usually disastrous affections from depositions of matter in the viscera, alluded to in aphorisms 58, 59, 60, 61, and 62, which are by no means so common when the patient is in better health; the connection of these with inflammation of the veins deserves a more close investigation than has as yet been bestowed upon it by civil or by military surgeons since attention was first drawn to it by me in 1815.

134. In secondary amputations in parts which have partaken of the extensive irritation which accompanies the original injury, more of the soft parts must be preserved, although they cannot be said to be unsound. In other words, the bone must be cut shorter, or the stump will be conical and bad, particularly if sinuses containing pus are found to run up between the muscles, or between them and the bone itself—a state very likely to give rise subsequently to caries.

In sawing the bone, it may be again stated, the point of the saw should incline downward, and when two-thirds of the bone have been divided, it should be made to cut perpendicularly, whereby the side next the operator is the last part divided; the hazard of splintering the bone at that moment will then be avoided, particularly if the limb to be removed be held with great steadiness.

135. In secondary amputations, twice, nay, three times the number of arteries will often bleed as in primary ones. In the thigh, the femoral artery should be drawn out with a tenaculum or spring forceps, and tied firmly with a single thread of dentists’ silk, one of the two ends being cut off close to the knot. The smaller the vessel, the smaller the thread required. Torsion or twisting the smaller vessels, so as to rupture their inner coats, answers very well in cases in which many small ones bleed. When a nerve is known to accompany an artery, it should be carefully separated from it.

136. If the bleeding should continue from above the ligature on the extremity of an artery, it is generally caused by some small branch given off from it, which has been cut so close to the trunk of the vessel as not to have been observed. In that case, the artery itself should be drawn out by the tenaculum or spring forceps until the bleeding point can be seen, and a ligature placed above it, when the piece below should be cut off with the first ligature applied. This inconvenience will be in general avoided by taking care to divide the principal artery at one stroke of the knife, and with it half an inch at least of the surrounding tissues, if the operation be done by the circular incision; if by flaps, the extent of the exposed arteries should be carefully examined, and the ligatures applied at the highest point of exposure, when all below should be removed.

137. When a tourniquet is used, and applied too close to the incised parts, it often prevents, even when loosened, the principal vessel from being found, from its having pressed on the ends of the muscles. If one be used, it should be removed as soon as possible after the principal artery has been secured. The repeated tightening and loosening of the tourniquet will cause more vessels to bleed in the end, and more blood to be lost, than if it had not been used; it ought not, therefore, to be resorted to when good assistance is procurable. In cases of this kind, in which the stump may not cease to ooze, the circulation being good, and sponging with cold water not effectual, the wound should not be finally closed for two, four, or more hours, until the oozing has ceased, and the parts can be freed from the coagulated blood, and brought together.

138. In cases in which union is not expected to take place, both ends of the ligature should be cut off; for union of the external parts is not to be desired in many instances of secondary amputation, particularly after serious injuries; the inflammation consequent on which has in some degree implicated the structures divided in the operation, rendering them less liable to take on the healthy action of adhesion. The soft parts should be simply approximated by two or more sutures, the edges of the wound having a piece of lint or fine linen between them. This precaution should be particularly attended to after a great battle, when it is perceived that from the air, the crowded state of the hospital, or the season of the year, the stumps, although they may appear to unite in the first instance externally, do not in reality do so internally.

139. It has been proposed to use ligatures made of cat-gut or other animal substances, which may be cut short, and left in the wound to be absorbed. This has taken place in some instances, while in others little abscesses have followed, allowing their discharge, and not expediting the cure, so that the practice has not prevailed; it is said that greater success has attended in America ligatures used in this way made of very fine shreds of the strong tendons of the large deer of that country. Ligatures should not be applied on large veins when they continue to bleed, if it can be avoided, although it has frequently been done without subsequent inconvenience. A little delay and moderate pressure will generally suffice to arrest the bleeding.

140. If the surgeon find, after completing the operation, that the bone cannot be sufficiently covered to make a good stump, a piece should be sawn off at once, and the error remedied, with little comparative inconvenience to what would occur afterward, if the bone be too long. No false shame should prevent its being done. If, however, the error have occurred, and the end of bone should become uncovered during the process of healing, it may be allowed to separate of itself, as it cannot be sawn off at this period without difficulty and much suffering; for an exposed surface will then remain, from which an exfoliation will take place before the stump can heal. In cases of great protrusion, an incision should be made down to the bone, which should be firmly held by strong forceps, or by a tube in which it will fit, when it is to be sawn off by the chain saw at a sound part, above that which has been exposed. The wound, in all cases, should be well supported by compress and bandage, to secure a good stump; whence the necessity for the bone being shorter than in those secondary amputations which are done at the period of election, and which will, on the contrary, often unite without difficulty. In primary operations, cold water is most applicable in the first instance; in secondary amputations, warmth by fomentations, rather than by even the lightest of poultices.